After noting that a patient with leukemia has thrombocytopenia, which action will the nurse plan to take?

Palpate lymph nodes for swelling.

Check temperature for elevation.

Inspect skin for bruising or petechiae.

Examine oral mucosa for ulceration.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Palpating lymph nodes for swelling is not directly related to thrombocytopenia. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to easy bruising and bleeding. Checking lymph nodes is more relevant in assessing for infection or malignancy.

Choice B rationale:

Checking temperature for elevation is important for assessing infection, which could be a cause of thrombocytopenia. However, in this context, inspecting the skin for bruising or petechiae is more specific to thrombocytopenia. Petechiae are small, red or purple dots that appear on the skin when platelet count is low.

Choice D rationale:

Examining oral mucosa for ulceration is essential in the assessment of conditions like oral cancer or infection. While thrombocytopenia could lead to bleeding in the oral mucosa, it is not the most specific or immediate concern in a patient with known thrombocytopenia.

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Correct Answer is D

Explanation

Choice A rationale:

Adequate platelet production does not explain the prolonged bleeding times in von Willebrand disease. These patients often have normal platelet counts, but their platelets do not function properly due to the absence or dysfunction of von Willebrand factor.

Choice B rationale:

Deficiency in intrinsic clotting system factor is not the primary cause of prolonged bleeding times in von Willebrand disease. The deficiency or dysfunction of von Willebrand factor, a protein that helps platelets adhere to the blood vessel walls and clot properly, is the key issue in this disorder.

Choice C rationale:

Impairment of the thrombin fibrinogen reaction does not directly relate to von Willebrand disease. This disorder primarily involves platelet dysfunction and variable factor VIII deficiencies, leading to prolonged bleeding times.

Choice D rationale:

Variable factor VIII deficiencies and platelet dysfunction are characteristic of von Willebrand disease. Factor VIII helps with blood clotting, and its deficiency, along with impaired platelet function, contributes to the prolonged bleeding times in patients with von Willebrand disease.

A. Purpura. B. Bruising. C. Petechiae. D. Ecchymosis.

Correct Answer is C

Explanation

Choice A rationale:

Purpura refers to purple or red discolorations on the skin caused by bleeding underneath the skin. It is larger than petechiae and ecchymosis and could be a sign of a more serious underlying condition. Petechiae are small, red or purple dots that appear on the skin due to minor bleeding from broken capillaries. In the context of leukemia and thrombocytopenia (low platelet count), petechiae are common due to impaired clotting mechanisms.

Choice B rationale:

Bruising occurs due to damage to blood vessels underneath the skin, resulting in the leakage of blood into the surrounding tissues. Bruises are typically larger than petechiae and can occur with various conditions, including trauma. In this case, the small 1-mm red macules are more indicative of petechiae.

Choice D rationale:

Ecchymosis refers to a larger area of subcutaneous bleeding or bruising. It is larger than both petechiae and purpura and often results from more significant trauma or bleeding disorders. The description of multiple 1-mm red macules is characteristic of petechiae rather than ecchymosis.

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After noting that a patient with leukemia has thrombocytopenia, which action will the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse recognizes that patients with von Willebrand disease are at risk for prolonged bleeding times for which reason?

Correct Answer is D

Explanation

With which term will the nurse document the finding after noting multiple 1-mm red macules when assessing the skin of a patient with leukemia and thrombocytopenia?

Correct Answer is C

Explanation

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